RESUSCITATION OF THE

POISONED PATIENT

Dr Andy McClellandDept. of Emergency Medicine

Auckland Hospital

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COMMON POISONINGS1. Substance abuse - ‘recreational’

Alcohol's, narcotics, sedatives, stimulants, hallucinogens

2. Intentional overdoseSuicide / Parasuicide

3. AccidentalMislabelled containers / paediatric age

group

4. Toxic exposuresGases , sprays, house fires

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A journey into the unknown?

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EVALUATION

1. Recognition of poisoning

2. Identification of the poison

3. Prediction of toxicity

4. Assessment of severity

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MANAGEMENT5. Supportive care

6. Prevention of poison absorption

7. Administration of antidotes

8. Enhancement of elimination

9. Prevention of re-exposure

10.Treat associated conditions/injuries

11.Disposition of the patient

“ The surest poison is time.”

Ralph Waldo Emerson (1803-1882)

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Suspect overdose / poisoning in any patient with

• altered level of consciousness

• unexplained signs & symptoms

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CLINICAL COURSE

•Non-toxic ingestion

•Acute toxicity

•Delayed toxicity

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INITIAL PATIENT MANAGEMENT

1. Condition upon arrival

2. Likely course of the poisoning

3. Other injuries / medical conditions

4. Patient compliance

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INITIAL PATIENT MANAGEMENT- if unwell

‘Team approach’

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INITIAL PATIENT MANAGEMENT- if unwell

Initial stabilisation

i. Triage

ii. Position patient

iii. A, B, C, D

iv. Blood glucose, Temperature

v. Monitor – SaO2, ECG, BP, LOC

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INITIAL PATIENT MANAGEMENT- if unwellAirway

• Adequacy, protection Breathing

• Always 0XYGEN; intubation/ventilation

Circulation • Large bore IV’s• Low BP due to decreased vascular

tone will respond to IV fluids /inotropes

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INITIAL PATIENT MANAGEMENT- if unwell

• Correct

• Hypoxia• Fluid balance• Electrolyte abnormalities• Acid / base abnormalities

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INITIAL PATIENT MANAGEMENT- if unwell

‘Coma cocktail’

50 mls 50% dextrose

naloxone 2 mg thiamine 100 mg

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POISONS INFORMATION

Ask a senior colleague!

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POISONS INFORMATION

• Text books– Ellenhorn– Haddad– Goldfrank

• On-line resources– Substance database (National Poisons Centre)– Poisindex– Toxindex

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AVOID INJURY TO STAFF

1. Barrier precautions where applicable

2. External decontamination

3. Adequate ventilation

4. Avert / control violent behaviour

5. Exclude at risk staff

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EVALUATION 1

•History

•Toxidromes

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EVALUATION 2- History

• Circumstances of discovery • Mental illness / suicide attempts• Reason for overdose

• Recreational• Self harm• Depression

• Additional injuries• Past medical history• Social history / family history

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EVALUATION 3- prediction of toxicity

1. The substances ingested

2. The quantities ingested

3. The time since ingestion

4. Any treatment to date

5. Concurrent medical conditions

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EVALUATION 4 - History

• Intoxicated patients can be unreliable historians

• 70% of intentional overdoses involve more than 1 substance

• Always consider substances which patients may not think are harmful

examples: aspirin, paracetamol, antihistamines

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EVALUATION 5- assessment of severity

• Vital signs• Physical examination

– Eyes• Pupillary size, nystagmus

– Neurological• Focal deficit is rare in overdose patients

– Skin– Odors

• Toxidromes

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EVALUATION 6- toxidromes1. Anticholingeric2. Cholingeric3. Sympathomimetic4. Narcotic5. Sympatholytic6. Extrapyramidal movement disorders7. Haemoglobinopathies8. Metal fume fever

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EVALUATION 7- Diagnostic testing 1

• ECG• Blood tests

– Paracetamol level for all patients– Arterial blood gas if unwell– U + E, glucose, anion gap, osmolar gap– FBE– Drug levels

• Urine drug screens

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EVALUATION 7-Diagnostic testing 2:

• Harrisons text

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EVALUATION 8- Diagnostic testing 3Consider specific tests

• CXR for pulmonary aspiration / oedema

• LFT’s / coagulation for liver damage

• Creatinine kinase for rhabdomyolysis

• Cervical spine XR / CT head for injury

• AXR for radio-opaque substances

PREVENTION OF POISON ABSORPTION

‘Decontamination’

Note - staff may be at risk

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DECONTAMINATION 1• Skin

• Remove contaminated clothing / wash skin

• Gastrointestinal Activated charcoal (in 1st hour post

ingestion)x Emesis (‘ipecac’ ) – rarely usedx Gastric lavage – rarely used Cathartics / whole bowel irrigation

• Eyes

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DECONTAMINATION 2- activated charcoal

• 1 gram / kg• Does not absorb

– Lithium– Heavy metals - iron– Alcohols/Solvents/

hydrocarbons– Caustics/strong acids– Cyanide– Pesticides

• Recovers 60% of poison if administered within the first hour

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DECONTAMINATION 3- cathartics

• Reduced gastrointestinal transit time => reduced time for drug absorption

• Osmotic agents – sorbitol, mannitol, MgSO4

• Contraindications – ileus / bowel obstruction– electrolyte imbalance

• Indication = debatible

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DECONTAMINATION 4-whole bowel irrigation

• May be useful for concretions &sustained-release preparations

• Polyethylene-glycol solution

• Administer at 1000 mls/hour until effluent is clear

• Rarely done but may be life saving if SR overdose

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ANTIDOTES

• Useful in < 5% of overdoses

• Know which antidotes are stocked

• Know how to get advice

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ANTIDOTES – some examples

Poison1. Paracetamol2. Narcotics3. Oral anticoagulants4. Carbon monoxide5. Organophosphates6. Betablockers7. Ca channel blockers8. Iron 9. Digoxin10. Methanol, ethylene glycol11. Cyanide

Antidote1. N-acetyl cysteine2. Naloxone3. FFP, Vitamin K4. oxygen5. Atropine, oximes6. Glucagon, insulin/glucose7. Calcium8. Desferrioxamine9. Digoxin Fab fragments10. ethanol, fomepizole11. Vit. B12, E-L kit,

Kelocyanor

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ENHANCEMENT OF ELIMINATION

1. Diuresis2. Multiple-dose activated charcoal3. Urinary pH manipulation

- salicylate4. Haemodialysis

- small molecules, low protein binding - e.g. salicylate, Lithium

5. Charcoal haemoperfusion- theophylline/barbiturates/carbamazepine

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TREAT ASSOCIATED CONDITIONS

• Trauma

• Chronic illness

• Environmental

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MONITORING

• Clinical observation– i.e. neurological assessments

• Pulse oximetry

• ECG monitoring– Minimum 6 hours if cardio-active drug– >24 hours if delayed release

preparation

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DISPOSAL 1

• Discharge

• Admission

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DISPOSAL 2• DischargePrerequisites:

1.Medical fitness

2.‘Safety check’

Formal assessment of suicide

and self-harm risk

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DISPOSAL• Admission 4

•Critical Care unit

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DISPOSAL 5• Admission

•Psychiatric unit

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DISPOSAL 6• Admission

•General Medical unit

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DISCHARGE ADVICE• COUNSELLING

– Community and alcohol counselling contacts for recreational drug abuse

• EDUCATION– Care-giver education for accidental

ingestion's• LEGAL

– OSH contact for work-related toxic exposures

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SUMMARY 1• Consider poisoning in any patient with

– ALOC– Unexplained signs and symptoms of any

nature

• Supportive care is the primary objective– TSS ‘Think simple stupid’

–A–B–C

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SUMMARY 2

• Evaluation of the patient

– Is thorough history taking from all sources

– Is occasionally aided by ‘toxidrome’ recognition

– Do not rely on toxicology screening tests

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SUMMARY 3• Management of the patient

– Depends on your assessment of A B C D

– Treating the patient not the poison

– Initiating clinically indicated treatment early

– Asking advice early

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Any questions?